a nurse is caring for a client who is post op day 1 after a total hip replacement although the client was alert with a normal affect in the morning by
Logo

Nursing Elites

NCLEX-RN

Health Promotion and Maintenance NCLEX RN Questions

1. A nurse is caring for a client who is post-op day #1 after a total hip replacement. Although the client was alert with a normal affect in the morning, by lunchtime, the nurse notes the client is confused, has slurred speech, and is having trouble with her balance. Her blood glucose level is 48 mg/dl. What is the next action of the nurse?

Correct answer: D

Rationale: A client with a blood glucose level of 48 mg/dl is experiencing significant hypoglycemia, as manifested by confusion, balance difficulties, and slurred speech. The nurse should work to correct this situation as rapidly as possible. The first measure that can be performed quickly and will have fast results is to give the client something to eat or drink that contains glucose, such as 6 oz. of orange juice. Administering a bolus of D20W through the IV (Choice B) would be too aggressive and could lead to complications in this scenario. Administering regular insulin (Choice C) would further lower the blood glucose level, worsening the client's symptoms. Contacting the physician (Choice A) is important, but immediate intervention to raise the blood glucose level is crucial to address the client's hypoglycemia.

2. A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?

Correct answer: C

Rationale: The correct nursing diagnosis in this situation is 'Fluid Volume Deficit related to post-partum hemorrhage.' Post-partum hemorrhage can lead to excessive bleeding, putting the client at risk of fluid volume deficit due to the loss of blood volume. This diagnosis is most appropriate as it addresses the immediate concern of fluid loss. 'Knowledge Deficit related to post-partum blood loss' (Choice A) is incorrect as the priority in this case is addressing the physical issue of fluid volume deficit rather than knowledge deficit. 'Self-Care Deficit related to post-partum neglect' (Choice B) is not relevant to the situation described. 'Body Image Disturbance related to body changes after delivery' (Choice D) is not the most appropriate nursing diagnosis in this context where the primary concern is fluid volume deficit due to post-partum hemorrhage.

3. As a nurse, you have been assigned to take over as charge nurse without any report after the previous charge nurse fell during her shift and was taken to the emergency room. At the end of the shift, you have made the assignments for the next shift's nurses and posted them. As the nurses come in, they begin to complain that the assignments make no sense based on patient acuity. One refuses to take her assignment and threatens to go home. What could you have done to prevent their dissatisfaction?

Correct answer: D

Rationale: Collaborating with the other nurses on your shift would have permitted them to provide the most updated information regarding patient status and acuity. Requesting their input into creating assignments would have provided shared governance and assurance that the unit staffing was arranged appropriately. Reviewing the notes of the previous charge nurse might not capture the real-time changes in patient conditions. Trying to contact the previous charge nurse in the emergency room may not be feasible or timely. Collaborating with the nurse manager could be helpful, but involving the nurses directly impacted by the assignments would have been more effective in addressing their concerns and ensuring appropriate patient care.

4. A woman has died as a result of a motor vehicle accident. She is listed as an organ donor, and her family is considering whether to comply with her wishes. Which of the following is true?

Correct answer: D

Rationale: In cases where a deceased person is listed as an organ donor, the family may have the final say on whether to proceed with organ donation, even if the individual had expressed their wish to donate. Physicians may prioritize the emotional well-being of the family over the wishes of the deceased, especially if organ donation could cause additional distress or trauma to the grieving family members. Therefore, it is possible for physicians to respect the family's decision not to proceed with organ donation, even if the deceased had previously expressed the desire to donate. This decision-making process underscores the importance of considering and respecting the perspectives and emotions of both the deceased individual and their surviving family members in organ donation scenarios.

5. A complication of osteoporosis is _______________?

Correct answer: D

Rationale: Joint deformity is a well-known complication of osteoporosis, leading to structural changes in the joints due to bone loss and fragility. Gouty arthritis and rheumatoid arthritis are distinct types of arthritis that are not direct complications of osteoporosis. Dorsiflexion is a movement related to the foot's range of motion and is not a typical complication of osteoporosis.

Similar Questions

A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?
You are caring for a Hispanic patient who is scheduled for surgery in the morning. A member of the surgery staff is in a hurry when she visits the patient to obtain surgical consent. You know that the patient speaks limited English and can see that he does not really understand what's being said. What is the most appropriate next action?
In which of the following examples would informed consent not be required?
The key to the prevention of a pandemic influenza is:
Which of the following types of antipsychotic medications is most likely to produce extrapyramidal effects?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses